Sexual Dysfunction in Men Living with Multiple Sclerosis

The most common problems experienced by men are difficulty or inability to get or hold an erection, decreased genital sensation, rapid ejaculation, and difficulty or inability to ejaculate. Difficulty acquiring or maintaining satisfactory erections seems to be the most common male complaint in MS, with frequencies ranging from 25 percent to 75 percent of those surveyed.

Erectile Problems

In some cases it may be hard to tell what is causing the erectile difficulties. Demyelination may directly affect erectile function. Medications may also be factors. Stress and anxiety produced by living with MS may contribute to or even be the primary cause of erectile dysfunction. Understanding the mechanics may help you and your partner.

In the presence of sexual stimulation, nerves in the spongy tissue of the penis release the chemical nitric oxide, stimulation the production of something called cyclic GMP which relaxes the smooth muscle in the penis, compressing the veins. When this happens, blood flows in but cannot get back out, and an erection occurs. Drugs used to increase GMP include sildenafil (Viagra
®), vardenafil (Levitra
®), and tadalafil (Cialis
®) All three drugs work by allowing an erection to occur when a man is adequately stimulated; they do not produce an erection in the absence of stimulation.

Other medication options include self-injection of alprostadil (Prostin VR
®) into the spongy tissue of the penis. Alprostadil is a vasodilator which increases blood flow in the penis. Most men report excellent results with this relatively painless injection that produces an erection without any stimulation being necessary. When give as a suppository (Muse
®), the medicine is placed into the opening at the tip of the penis.

Additional Options Available

The vacuum tube and band device can be an effective alternative to medications. It consists of a plastic tube with a pump and band for the base of the penis. The tube fits over the penis. The hand pump produces vacuum pressure, and the band constricts the veins. This makes the penis fill up with blood, producing an erection. The tube is then removed. Because of its effectiveness and availability, the vacuum tube and band are widely used by men with MS.

Catalogs and specialty stores also sell rubber rings (aka cock rings) meant to be worn at the base of the penis. These rings reduce blood flow out of the penis and can help to maintain erections, but cannot be used for more than 30 minutes. The vacuum tube and band may be prescribed by physicians, including urologists.

Several types of penile prostheses, semirigid and inflatable, are also available for men who aren’t successful with the medications or tube and band device.
While these have been used very successfully by many men, they require a surgical procedure that brings with it some risk of infection

IT’S NOT ALWAYS THE ERECTION

In addition to erectile problems, surveys of men with MS have identified decreased genital sensation, fatigue, difficulties with ejaculation, and decreased interest or arousal as fairly common complaints. In one of the most comprehensive and methodologically sound surveys to date, only 35 percent of men reported no sexual problems, and many reported multiple problems.

Decreased Genital Sensation
Sensory changes in the genital area may impair pleasure or interfere with ejaculation. Manual and/or oral stimulation, or the use of a vibrator, may provide enough extra sensory input for erection and orgasm. Uncomfortable genital sensory disturbances, including burning, pain, or tingling, can sometimes be relieved with gabapentin (Neurontin
®), carbamazepine (Tegretol
®), phenytoin (Dilantin
®) or divalproex (Depakote
®) or by a tricyclic antidepressant such as amitriptyline (Elavil
®).

Ejaculation Problems

Some men with MS may be unable to ejaculate. Others may experience what is known as a "retrograde" or backward ejaculation, in which the ejaculate travels back up into the body. Although this problem is not harmful in any way, it can interfere with efforts to conceive a child. Men who are unable to ejaculate can be given medication or other treatment to stimulate the process.

Orgasmic Dysfunction

MS can interfere directly or indirectly with orgasm. In women and men, orgasm depends on nervous system pathways in the brain (the center of emotion and fantasy during masturbation or intercourse), and pathways in the sacral, thoracic, and cervical parts of the spinal cord. If these pathways are disrupted by plaques, sensation and orgasmic response can be diminished or absent.

In addition, orgasm can be inhibited by secondary (indirect physical) symptoms, such as sensory changes, cognitive problems, and other MS symptoms. Tertiary (psychosocial or cultural) orgasmic dysfunction stems from anxiety, depression, and loss of sexual self-confidence or sexual self-esteem, each of which can inhibit orgasm.

Treatment of orgasmic loss in MS depends on understanding the factors that are contributing to the loss, and appropriate symptom management of the interfering problems.

Decreased Libido

Diminished libido is frequently associated with a decrease in sexual fantasies and can sometimes be stimulated by increasing sexual imagery and fantasy. Historically, most sexual literature, videos, and magazines have been developed to appeal to a male rather than female audience. Recently, however, some sexual videos are being marketed to appeal to couples and women. They typically include fewer close-ups of genitals during orgasm and have more emotional and romantic content and imagery. When libido is partially intact but difficulty sustaining arousal and/or having orgasms occurs, sharing sexual fantasies or watching sexually oriented videos together may help sustain arousal. Similarly, introducing new kinds of sexual play into sexual behavior can help maintain arousal and trigger orgasms.